Chapter Four. The principles of combined movement assessment. Chris McCarthy

Transcription

1 Chapter Four 4 c0020 The principles of combined movement assessment Chris McCarthy CHAPTER CONTENTS u0010 Subjective examination u0015 Physical examination u0020 Observation...54 u0025 Functional u0030 Active movements...56 u0035 Degree of symptom reproduction deemed acceptable...57 u0040 Prime movement and prime combination. 57 u0045 Muscle assessment...59 u0050 Passive movement and mini-treatments. 59 u0055 Assessing for the suitability of manipulative thrust techniques...60 u0060 Cervical spine case study u0065 Lumbar spine case study p0070 The purpose of clinical examination is not simply to gather as much information as is possible in the time available. Often the inexperienced clinician can spend an entire examination gathering data with little evaluation of its clinical relevance. As manual therapists we provide our patients with incredibly sensitive examinations. The volume and sophistication of our examination procedures is immense. However, we may occasionally fail to grasp the problem of specificity. We must find a balance between gathering enough information to prioritize the patient s most significant dysfunction whilst not being distracted by the less relevant dysfunctions we discover. p0075 We are essentially searching for the patient s predominant dysfunction or fault in order to direct our intervention towards it. The process of ranking the importance of our findings requires that we test the hypothesis of predominant dysfunction throughout our interaction with our patients. In short, during the examination of patients we are considering if our hypothesis will guide treatment more effectively than the next most likely hypothesis. In addition, during treatment we should be continually considering if our chosen intervention is in fact more effective than the next most likely intervention. This process of analytical assessment is not new and was advocated by Maitland (1986) and Grieve (1988, 1991) over 30 years ago. Simply gathering huge quantities of information that is neither discriminatory nor influential in management represents a failure in our duty of care to our patients. The purpose of clinical examination is to evaluate valid information that will facilitate the prioritization of likely diagnoses and strategies of management. In other words, our duty to our patients is to ensure we are identifying their predominant dysfunction/fault and to continually ensure that we are providing the most effective management strategy at the time. Ensuring we adhere to this principle will ensure we are facilitating recovery as quickly as possible. It could be argued that the primary objective of manual therapy is to facilitate recovery as quickly as possible. On the whole, the conservative management of most musculoskeletal dysfunctions will facilitate recovery. Manual therapy s role is in the acceleration of this process. Thus, ensuring our treatment choice is making more difference, more quickly than the next most likely choice of treatment is a crucial responsibility. p0080 ã 2010, Elsevier Ltd.

2 SECTION ONE Combined Movement Theory s0010 Subjective examination p0085 During the initial consultation the therapist will begin to form an impression of the patient based on verbal and non-verbal communication. Expert clinicians form an impression regarding diagnosis, management and expectations of the patient very quickly. Mixed methods of clinical reasoning are utilized in this process as outlined in Chapter 3. p0090 The diverse nature of musculoskeletal dysfunction rarely allows the definitive identification of definitive patterns of presentation. The clinician is frequently required to make reasoned judgements as to the predominant dysfunction from several alternatives. Some of the typical judgements required are listed below. This is by no means an exhaustive list. The process of establishing that one treatment approach is superior to another begins during the initial consultation with the patient. Early in the initial interview with a patient, the therapist should look for answers to the following questions. s0030 Is this patient s presentation suitable for a manual therapy approach? u0070 Is this patient presentation sounding like I should explore further with an assessment of biomechanical dysfunction? u0075 Does this patient s presentation suggest that a more psychosocial approach may elicit effective treatment strategies? s0035 Which patterns of presentation does this presentation match with? u0080 Does the presentation fit a pattern of presentation I have encountered before? u0085 If so, what is it that makes this patient s presentation fit this pattern better than the next most likely pattern? u0090 What questions and tests do I need to use to test this hypothesis? s0040 Does the functional fault have a directional quality? u0095 In what combination of positions are symptoms reproduced? u0100 In what combination of positions are symptoms reduced? s0045 What is the likely source of the directional fault? u0105 Does the presentation have predominantly arthrogenic features? Does the presentation have predominantly myogenic features? Does the presentation have predominantly neurodynamic features? Is this predominantly a control or impairment fault? Does the presentation suggest a dysfunction in control of movement? Does the presentation suggest a dysfunction associated with limitation (or impairment) of movement? Is it acceptable to reproduce symptoms are they severe? Is the faulty position producing severe pain? Is positioning in the faulty position likely to cause a latent or long-term exacerbation of symptoms? Is there a position that will allow examination and treatment whilst avoiding unacceptable symptom reproduction? Is it likely that caution needs to be taken due to a patho-anatomical reason that would make the use of combined movement theory (CMT) unwise? See the contraindications to manual therapy in the box below. What is the predominant pain mechanism? Is the patient s predominant pain mechanism: nociceptive, peripheral neurogenic, central sensitivity, autonomic or affective? A proforma planning sheet can be found on the CD. See Figure 4.1. Prior to the conduct of a physical examination using the CMT approach the patient should be informed of your plans and the risks and benefits of the approach against other approaches. By examining the expectations of the patient the suitability of utilizing a CMT approach can be established. If the patient s expectations of treatment are radically different to the therapist s, a discussion of future management should ensue. A detailed biomechanical assessment of spinal dysfunction may be unwarranted if the patient is expecting and consenting only to generic advice and exercise. u0110 u0115 s0050 u0120 u0125 s0055 u0130 u0135 u0140 u0145 s0060 u0150 b0010 p0215 p0370 p

3 The principles of combined movement assessment CHAPTER 4 b0015 b0015 Clinical point Contraindications to spinal passive movement that takes a joint to the end of passive range or thrust techniques s0065 Bone p0220 Any pathology that has led to significant bone weakening: u0155 Tumour, e.g. metastatic deposits u0160 Infection, e.g. tuberculosis u0165 Metabolic, e.g. osteomalacia u0170 Congenital, e.g. dysplasias u0175 Iatrogenic, e.g. long-term corticosteroid medication u0180 Inflammatory, e.g. severe rheumatoid arthritis u0185 Traumatic, e.g. fracture s0070 Neurological u0190 Spinal cord compression u0195 Cauda equina compression u0200 Nerve root compression with increasing neurological deficit s0075 Vascular u0205 Aortic aneurysm u0210 Bleeding into joints, e.g. severe haemophilia u0215 Cervical artery dysfunction (Kerry et al, 2008a, 2008b) s0080 Relative contraindications p0300 Special consideration should be given prior to the use of spinal manipulative thrust techniques in the following circumstances: u0220 Adverse reactions to previous manual therapy u0225 Disc herniation or prolapse u0230 Inflammatory arthritides u0235 Pregnancy u0240 Spondylolysis u0245 Spondylolisthesis u0250 Osteoporosis u0255 Anticoagulant or long-term corticosteroid use u0260 Advanced degenerative joint disease and spondylosis u0265 Psychological dependence upon spinal manipulative thrust techniques u0270 Ligamentous laxity u0275 Arterial calcification u0280 Hypertension (diastolic >95)incervicalmanualtherapy (See Gibbons & Tehan, 2001a,b; Grieve, 1991.) s0085 Is the patient suitable for a biomechanical assessment of their movement fault? p0380 Patient presentations suggestive of a predominant mechanical influence on symptoms are suitable for detailed biomechanical assessment and treatment. Presentations that do not feature mechanical/movement influences on symptomology suggest that specific positions and movements may not be the predominant influences to be addressed during examination and treatment. Thus, patients who have constant symptoms, regardless of positioning, will be unlikely to benefit from management with a positional bias. Patients with central sensitization or inflammatory neurogenic pathology ( irritable patients (Maitland, 1985) have no mechanical predominance. How acceptable is it to reproduce symptoms? Patients, seeking manual therapy, present with pain and largely judge their improvement by an amelioration of their pain. In the process of assessing the effect of testing and treatment, changes in pain are assessed. However, in cases where pain is severe, it is unacceptable to reproduce pain and inappropriate to treat an underlying mechanical dysfunction whilst reproducing pain. Thus, prior to any physical testing the therapist must be clear regarding the degree to which pain is to be reproduced during their interaction with the patient. In certain presentations it may be deemed acceptable to fully reproduce the minor discomfort the patient is seeking help for, in order to fully relieve it. However, in situations where pain is severe this is unacceptable. Using positions that can reduce the likelihood of reproducing severe pain is one of the key advantages of CMT. Clinical relevance If it is not acceptable to reproduce symptoms, the condition is severe. If it is acceptable it is not. Use a nominal (yes/no) approach to this decision and your clinical reasoning will be decisive and more reasonable. What is the functional of the positional fault? Patient presentations, suggestive of the suitability of a CMT approach, have symptoms predominantly influenced by specific positions or movements. Patients can often demonstrate these movements or positions and reproduce them in the course of replicating a functional activity. For example, patients with anterior stretch patterns of the mid cervical spine often relate symptom reproduction with activities inducing ipsilateral lateral flexion and rotation, e.g. reversing the car. The monitoring of change in the functional, during examination and treatment is a crucial monitor of treatment effectiveness. Again, the concept of a functional is a long- s0090 p0385 b0020 p0390 s0095 p

4 SECTION ONE Combined Movement Theory established tenet of the Maitland concept (Maitland, 1986) and at the heart of CMT. s0100 What is the region of the spine that is likely to be faulty? p0400 The biomechanical interpretation of patient presentation can allow the therapist to judge the location of regions of dysfunction. Careful questioning can elicit functional activities that influence specific regions of the spine. For example, the influence of breathing on thoracic movement can provide valuable inference towards spinal or rib dysfunctions. s0105 What is the predominant hypothesis for the source and mechanism of symptom production and the next most likely hypothesis that will be tested against it? p0405 It is crucial to form hypotheses regarding the underlying source and mechanism of symptom production as you recognize presentation patterns. As a pattern of presentation begins to emerge the use of follow-up questions will establish a good fit with this pattern. Having identified a match with a recognizable pattern, the manual therapist should test the assumption that this hypothesis is predominant by comparing the match with the next most likely pattern. For example, having established that a patient s presentation matched an arthrogenic presentation, one would expect the presentation to be less well matched with a myogenic presentation. In order to facilitate this process it can be useful to develop a library of stock questions and tests for common presentations. p0410 The use of these strategies will facilitate the therapist s reasoning regarding the appropriateness of using CMT, the most likely hypotheses for aetiology of symptoms, the extent and direction of movements to be included in the examination and most importantly the starting positions in which assessment and treatment will be undertaken. p0415 Figure 4.1 shows a suggested planning sheet for use in clinical reasoning during the CMT examination. s0110 Physical examination p0420 The objective examination will follow the subjective examination and is conducted in light of the considerations and clinical reasoning process outlined in this book. The object of the physical examination is not to form a long list of impairments with little evidence of their relative contribution to the patient s dysfunction. The physical examination should allow the hypotheses, generated following the subjective examination, to be tested. Thus, the examination should be structured to allow this process to occur. In order to assess the influence of the testing procedures themselves on a patient s dysfunction the physical examination should be split into components. The order in which components of the examination are conducted will be guided by the subjective examination. A clinician may hypothesize that the predominant mechanism of symptom production is related to a restriction in articular mobility rather than, e.g. a restriction in overlying muscle mobility. In this case, the examination would be structured to examine the articular system, assess its influence on the fault, and then assess the muscular influence and reassess that system s influence on the fault. In this way, in addition to gathering information from each component of the examination the relative influence of the components can be evaluated. Each component begins with an assessment of movement fault (using the patient s functional ), testing procedures and a subsequent reassessment of functional. See Figure 4.2. Observation Observation of static posture can give valuable insight into the likely mechanical presentation of symptoms with movement. A number of static features will help in the interpretation of active movement. A deep skin crease may suggest hypermobility at the level whilst flat sections with reduced muscle bulk may suggest hypomobility. Defined muscle borders may indicate hypertonicity whilst unilateral atrophy may indicate local neuropraxia or trophic change. See Figure 4.3. Functional The functional is the term given to the combination of plane movements that the patient has identified to take them into their most aggravating position. This position identifies the movement fault, whilst the quality, range and speed of movement from neutral into this position and return, should be analyzed in depth. The combination of physiological movements that constitute the functional will provide invaluable information about the starting position that should be adopted for passive movement assessment and treatment. In addition, the three-dimensional components of this position will identify the movements p0425 p0430 s0115 p0435 s0120 p

5 The principles of combined movement assessment CHAPTER 4 OBJECTIVE EXAMINATION PLAN List your hypotheses for the nature of the condition Which two hypotheses will you test against each other in the initial physical examination? Primary... Secondary... Is the nature of the condition severe? Yes No Is the nature of the condition irritable? Yes No To what point are you allowing movement to occur? Before pain To pain To end What is your functional /re-test marker?... What is the primary pain mechanism of this patient s condition? Nociceptive Peripheral neurogenic Central Autonomic Affective To what extent will you perform a neurological exam? None required Local peripheral Lower motor neuron, upper motor neuron, limbs Lower motor neuron, upper motor neuron, limbs and cranial What is the weighting of the following components of the problem? % Radar plot Arthrogenic Arthrogenic Myogenic 100 Neurogenic Osteogenic Myogenic Inflammagenic 50 Psychogenic Viscerogenic Neurogenic 0 Sociogenic Pathogenic Pathogenic Inflammagenic Viscerogenic Osteogenic Sociogenic Psychogenic Likely first treatment: In:... Will:... Comments/cautions: f0010 Figure 4.1 Clinical reasoning form. 55

6 SECTION ONE Combined Movement Theory First hypothesis Arthrogenic Functional Posterior stretch Second hypothesis Myogenic Figure 4.2 A flow chart showing the suggested compartmentalization of the physical examination. The functional is at the head of the differentiation. Two common differentiations are displayed: primary arthrogenic versus primary myogenic. f0015 Observation Observation Hypomobile mid cx Hypertonic muscles ipsilaterally Active movement Active movement Prime movement Prime combination Passive movement In the correct starting position Palpation Passive movement Starting position Palpation Muscle stretch Reassess functional PPIVMS Reassess functional PAIVMS Reassess functional Muscle contraction Reassess functional that should be examined in isolation. Change in the range of movement and pain experienced in the functional position will most accurately reflect overall improvement in the patient s impairment. Active movements s0125 f0020 Figure 4.3 Active extension, right rotation, showing hypomobility of L5, L4, with movement (and skin crease) at L3. IN: standing; DID: active extension of lumbar spine. Segmental restriction of L4/L5 demonstrated. Active movements should be carefully controlled by the therapist. It is important that the patient moves to a point in range that is appropriate for their severity and nature. Simply asking a patient to extend their back will not give adequate guidance about how acceptable it is to reproduce their pain. A patient with very severe pain may be eager to please the therapist and extend beyond the onset of pain causing an exacerbation, or alternatively, may be fearful of p

7 The principles of combined movement assessment CHAPTER 4 s0130 movement and not move to the point that reproduces symptoms. Variability on interpretation of incomplete commands will lead to difficulties with the reliability of testing. Thus, clear commands regarding how far to move in relation to reproduction of symptoms should be included in the commands. A decision about how acceptable it is to reproduce symptoms will need to have been made prior to undertaking this section of the examination. Degree of symptom reproduction deemed acceptable p0450 Having agreed on this the therapist must use clear commands to instruct the movement conducted: u0285 If the agreed degree of symptom reproduction is nil, then at the completion of a combination of movements, the therapist s command should state clearly stop before the pain starts. u0290 If the agreed degree of symptom reproduction is full, then at the completion of a combination of movements, the therapist s command should be move as far as you possibly can. u0295 If the agreed degree of symptom reproduction is partial then at the completion of a combination of movements, the therapist s command should be stop when the pain starts. p0470 Good control of symptom reproduction will enable the combination of movements needed to fully assess the patient s movement dysfunction. Disregard of this important control will lead to situations where the patient s symptoms are exacerbated or under-evaluated. hypomobile section of the spine. The patient can find it difficult to move the hypomobile segments as they move at areas presenting the least resistance to movement and move only at the hyper-mobile segments. This can lead to a situation where symptoms are not reproduced as the symptomatic levels are not being tested, during the test movement. False negatives can occur unless this error in clinical reasoning is considered. Consequently, it is important to guide patients to move at regions you consider likely to be symptomatic during active movement testing. See Figures 4.4, 4.5 and 4.6. The active movement examination is structured to examine the movements most relevant for the patient s impairment. The functional will have provided the examiner with evidence that certain movements are more important in reproducing the dysfunction than others. The functional position will justify a detailed examination of the three movements that constitute it. The next stage in examining the biomechanical features of the impairment is to examine each of the three components of the position to establish which p0485 b0025 p0475 Clinical point If the patient has severe pain at rest the examination will be aimed at finding the movement and position that most reduces pain and it will typically involve finding starting positions for assessment and treatment in the quadrant opposite to the dysfunctional quadrant. s0135 Prime movement and prime combination p0480 Whilst observing active movements, particular attention should be paid to ensuring that the patient moves areas of the spine that are impaired. Very often a patient will have developed hypermobility above a Figure 4.4 Active movement of the lumbar spine. Here, movement of the stiff L4/L5, L5/S1 segment is facilitated by fixing the sacrum with one hand whilst guiding movement to the low lumbar spine. IN: Standing, bed edge support, lumbar extension; DID: active right lateral flexion, range assessment. Note the wide stance required to ensure balance. f

8 SECTION ONE Combined Movement Theory Neutral Right rotation Extension Right rotation Sensitized nociceptors C5 C6 f0030 f0035 p0490 p0495 Figure 4.5 Active movement of the low thoracic spine. Here, movement of the stiff T10/T11 segment is facilitated by fixing the lumbar spine with one hand whilst guiding movement to the low thoracic spine. IN: sitting, lumbar neutral; DID: active left rotation, low thoracic range assessment. Figure 4.6 Active, guided low cervical flexion. IN: sitting, cervical flexion; DID: active assisted left rotation of the low cervical spine. The patient is given feedback on where to move. two movements are the most important, and within these two movements, which is of primary importance or prime movement. The primary movement has an importance within CMT in both the classification of syndromes and in selection of starting positions for treatment. The movement itself is defined as being the movement that either reproduces the patient s signs and/or symptoms most completely (when it is appropriate to do so) or most completely relieves symptoms when the condition is too severe to reproduce symptoms. Having established the prime movement in one plane it should be explored by repeating the movement when combined with another movement, in Figure 4.7 The illustration shows the selective tension of articular and peri-articular tissue with progressive addition of three planes of movement. A progressive increase in anterior stretch is observed with the addition of extension to right rotation (right rotation being coupled with right lateral flexion). another plane, which will move one side of the motion segment in the same direction. In a simplified model of spinal biomechanics extension, ipsilateral rotation and ipsilateral lateral flexion will cause the superior joint facet to move down the inferior segment s joint facet (see Fig. 4.7). Flexion, contralateral flexion and contralateral rotation will cause the superior facet to move up the inferior segment s joint facet. For example, right rotation is the patient s prime movement, reproducing right-sided neck pain. Exploring this movement by examining right rotation in extension and extension in right rotation will elicit which combination is the primary combination. The prime combination will closely resemble the patient s functional. The primary combination holds a crucial place in CMT as it is the starting position where passive movement assessment is conducted. By positioning the spine in the position of dysfunction the addition of passive movements will be more influential in reproducing symptoms and more likely to alter movement dysfunction than if conducted in a neutral position. Passive movement conducted in neutral will rarely be sufficient to reproduce symptoms adequately. When performed in a position related to dysfunction, the application of passive movement or muscle contraction will provide valuable information on, not only the quality and control of movement, but also the effect of the test on the dysfunction. Finding the primary combination is the process by which the clinician can be sure that passive movement testing will be the most informative and that treatment in this position will have the quickest effect on dysfunction. A two-dimensional equivalent would be the need to assess and treat a patient with a 10 loss of elbow extension at this f0040 p0500 p0505 p

9 The principles of combined movement assessment CHAPTER 4 s0140 position, not at 90 of elbow flexion (the equivalent of assessing in neutral). Muscle assessment p0515 The assessment of muscular influences on the spinal dysfunction should involve an assessment of muscular activity (tone) in the primary combination starting position. The degree and location of hypertonicity can be readily palpated in local, deep paraspinal muscles and the overlaying, superficial, musculature (see Figs 4.8 and 4.9). At this point an assessment for trigger points (Travell & Simmons, 1998) can be Table 4.1 Listing the musculature that becomes over or under-active in common spinal pain syndromes (Chaitow, 2006) Short/facilitated/over recruited Occipital extensors Sternocleidomastoid Scalenes Upper trapezius Long/inhibited/under recruited Upper cervical flexors (rectus capitis anterior) Deep cervical flexors (longus colli) Low cervical extensors (iliocostalis) Lower/middle fibres of trapezius t0010 Levator scapulae Rhomboids Subscapularis Serratus anterior Pectoralis minor Pectoralis major Latissimus dorsi Iliopsoas Tensor fascia latae Gluteal muscles Abdominal muscles Quadratus lumborum f0045 Figure 4.8 Palpation of anterior paraspinal muscles, fascia and neurovasular structures. IN: supine, neutral; DID: palpation of anterior low cervical musculature. Special care must be taken to ensure that the flat of the thumb is used to avoid painful pressure. conducted, followed by an assessment of extensibility (Chaitow, 2006) of the superficial phasic muscles that have a tendency to become hypertonic in the presence of spinal pain. See Table 4.1. During this process, hypertonic muscles are passively lengthened either locally, globally or both and a temporary reflexogenic reduction in muscular activity can be induced. Consequently, these tests are effectively mini-treatments of the muscular system. The effect of this mini-treatment on the patient s functional can be immediately assessed. In this way the relative contribution of the myogenic system can be assessed against the arthrogenic system by mini-treating first one system and then another. See Figures 4.10 and p0520 p0525 f0050 Figure 4.9 Palpation of upper thoracic soft tissue tone. IN: prone, neutral; DID: soft tissue tension palpation, upper thoracic spine. Firm pressure will be needed to pick and work through the superficial musculature. Bands of resistance to movement will be palpated. Passive movement and mini-treatments Having established the optimal position to induce passive movement at the motion segments moving dysfunctionally, an assessment is made to determine which passive movement will be the most effective s0145 p

10 SECTION ONE Combined Movement Theory f0055 Figure 4.10 Post-isometric relaxation technique for the right, posterior paraspinals. IN: sitting, thoracic flexion; DID: isometric contraction resisting left rotation of T1 on T2. The patient is told to Don t let me win as the neck is moved towards more flexion and rotation. The patient will contract the extensors and right rotators. An isometric contraction can be held for 6 10 seconds. requires a degree of skill to perform. Whilst the treatment is of a short duration, in order to fit into the assessment process without becoming too time consuming, it must be enough of a dose of treatment to evoke a change in muscle activity and/or joint mobility. Thus, the examiner needs the palpatory skill to be able to tell when these features have subtly changed. With practice the skilled manual therapist can be as confident in discriminating this change in mobility as they have in their ability to discriminate between a normal or hypomobile joint on initial assessment. If we really are striving to provide treatment that is the most efficacious option we must prove that the specific treatment we are proposing is indeed more effective at reducing the dysfunction than the next most likely option. Testing one treatment against another is something we do whilst treating patients, however, the incorporation of this principle during the assessment process is of particular importance with the CMT approach. p0535 p0540 Assessing for the suitability of manipulative thrust techniques s0150 f0060 Figure 4.11 Post-isometric relaxation technique for the right, anterior paraspinal muscles. IN: supine, neutral extension; DID: isometric contraction resisting extension and right rotation. The patient performs an isometric contraction in response to AP pressure. Contraction of the right anterior musculature is produced. See video clip number 4 at reducing the dysfunction. This will involve deciding between accessory and physiological passive movement and between particular combinations of both. One method of deciding between two likely treatment options is to compare the immediate effectiveness of using the treatments. Even a short period of treatment, if applied in the correct starting position, will have an immediate effect on movement dysfunction. The patient will be able to discriminate between the treatment effects and tell you which treatment to use! Local movement impairment, specific to one or two spinal segments, can present with hypomobility in the contralateral side glide that accompanies ipsilateral lateral flexion and rotation. Acute muscle spasm or long-standing movement impairment can lead to a perceptible change in the passive range of contralateral side glide during ipsilateral lateral flexion. When visualizing the quality of resistance to passive movement the movement diagram, developed by Maitland (1986) is useful. When passively inducing lateral flexion at one spinal segment a perception of the profile of resistance to movement can be drawn. Profiles of resistance that are short in range represent a crisp end feel, whilst a long range of resistance profile will feel bouncy. Finally a movement that has no range of resistance and comes to a complete stop immediately resistance is felt, will feel solid. See Figure Segments that do not have this crisp profile do not generally cavitate in response to a high velocity thrust. Thus, unless the therapist assesses lateral flexion and its associated contralateral side glide the rationale for choosing a manipulation technique over a mobilization technique is less clear. The assessment of accessory glides does not afford the information to make this judgement. The assessment of p0545 p

11 The principles of combined movement assessment CHAPTER 4 R2 IV- R1 R2 III+ Figure 4.13 Assessment of the contralateral glide with right lateral flexion of the lumbar spine. IN: supine, cervical extension, left rotation, right lateral flexion; DID: passive right lateral flexion, Grade IV thrust of the C4 segment on C5. Thrust starts before the beginning of resistance and stops just after the beginning of resistance. f0070 R1 R2 R1 f0065 Figure 4.12 This illustration shows the profiles of resistance to segmental movement that can be detected with passive intervertebral movement testing. The top diagram represents a crisp profile of resistance, the middle a bouncy feel and the bottom figure a solid feel. Only the top profile signifies that a manipulative thrust will be successful in inducing cavitation. Figure 4.14 Assessment of contralateral lateral glide with ipsilateral lateral flexion in a combined starting position, prior to application of a IV thrust technique. IN: sitting, thoracic extension; DID: right lateral flexion of T12 on L1. As the upper segment is ipsilaterally side-flexed the motion segment is contralaterally side glided. f0075 segmental lateral flexion can be conducted in combined starting positions in order to fully examine for the presence of this crisp profile of resistance. See Figures 4.12, 4.13, 4.14, 4.15 and In the following case studies there are two worked examples of the practical application of CMT approach during initial assessment, with one example from the cervical spine and one from the lumbar spine. p

12 SECTION ONE Combined Movement Theory f0080 Figure 4.15 Assessment of the contralateral glide associated with ipsilateral flexion of the low lumbar spine. IN: left side-lying, flexion; DID: right lateral flexion with left side glide at the motion segment. As the lumbar spine is laterally flexed, firm pressure is applied towards the bed. Figure 4.16 Assessment of resistance profile of contralateral glide in a combined position used to induce cavitation. IN: flexion, left lateral flexion, right rotation; DID: right rotation combined with contralateral glide downwards. The combined starting position for a Grade IV rotation, thrust technique. f0085 b0030 s0155 s0160 p0560 s0165 p0565 s0170 p0570 s0175 p0575 s0180 p0580 CERVICAL SPINE CASE STUDY INITIAL INTERVIEW Symptomology A 22-year-old female sought treatment for pain in the right cervical spine and right shoulder. The pain was located in the lower cervical spine and referred into the right shoulder across the right supra-scapula fossa (Fig. 4.17). The pain was not radicular in quality but severe (8/10). There was no suggestion of an upper motor neuron lesion and no indication of other red flags. There were no features suggestive of segmental cervical instability or shoulder derangement. There was no history of cervical locking, catching or weakness. There was no headache. Relevant history Symptoms developed over a 6-day period following a mild, rear shunt whiplash injury, a week previously. Behaviour of symptoms Pain was reproduced with low cervical flexion and left lateral flexion. Sitting with the neck in this position reproduced symptoms within 2 minutes. The symptoms were eased immediately, by positioning the lower cervical spine in extension and right lateral flexion. No latent pain was exhibited. Diurnal pattern There was no stiffness in the cervical spine in the morning. Shoulder pain developed in the evening. Sleep was not disturbed. Special questions The patient s general health was good. There was no weight loss, no dizziness, no dysphagia, no dysarthria, Figure 4.17 Cervical spine case study pain chart. no diplopia, no raised blood pressure, and no symptoms of cervical artery dysfunction. Radiographs of the cervical spine were normal. The patient was not currently taking any anticoagulant or steroid therapy and had received no benefit from anti-inflammatory medication. There was no history of locking, clunking or giving way of the shoulder, with no history of trauma. See the completed planning sheet in Figure f0090 p

13 The principles of combined movement assessment CHAPTER 4 OBJECTIVE EXAMINATION PLAN List your hypotheses for the nature of the condition Posterior facet capsule sprain Posterior paraspinal strain Posterior annular disc sprain... Which two hypotheses will you test against each other in the initial physical examination? Primary... Articular predominance... Secondary... Myogenic predominance... Is the nature of the condition severe? Yes No Is the nature of the condition irritable? Yes No To what point are you allowing movement to occur? Before pain To pain To limit What is the functional /primary re-test marker?... Flexion contralateral, lateral flexion quadrant... What is the primary pain mechanism of this patient s condition? Nociceptive Peripheral neurogenic Central Autonomic Affective To what extent will you perform a neurological exam? None required Local peripheral Lower motor neuron, upper motor neuron, limbs Lower motor neuron, upper motor neuron, limbs and cranial What is the weighting of the following components of the problem? % Radar plot Arthrogenic 50 Arthrogenic Myogenic Neurogenic 1 Osteogenic Myogenic Inflammagenic 2 50 Psychogenic 1 Viscerogenic Neurogenic 0 Sociogenic 1 Pathogenic 1 Pathogenic Inflammagenic Viscerogenic 1 Osteogenic 3 Sociogenic Psychogenic Likely first treatment: In: Extension, right lateral flexion quadrant... Will: Anterior capsular stretch, large amplitude movement, in resistance (Grade III)... Comments/cautions: Pain relief approach, progressing to a stretch of the tissues driving the nociceptive pattern of presentation f0095 Figure 4.18 Objective examination plan for the cervical spine. 63

14 SECTION ONE Combined Movement Theory Prime movement = left lateral flexion Prime combination = left lateral flexion followed by flexion. 3 /4 full range Right-sided cervical and shoulder pain Severe PHYSICAL EXAMINATION Observation There was no atrophy of the cervical musculature. There was an increase in muscle tone of the right sternocleidomastoid, upper fibres of trapezius and levator scapula and right scalenes. Active movement Pain was reproduced earliest in range with left lateral flexion. Restriction to flexion was apparent at the C5/C6 level. Pain was reproduced further into range with flexion than with left lateral flexion. Restriction to movement was most obvious in the mid cervical region. See Figure s0185 s0190 p0590 s0195 p0595 f0100 Figure 4.19 Box diagram showing the prime combination for the patient. Functional Flexion, left lat flex Figure 4.20 Flow chart of differential examination for the cervical spine. f0105 First hypothesis Posterior facet capsule sprain Second hypothesis Posterior musculature strain Observation Postural positioning malalignment Observation Muscle atrophy Hypertrophy Hypotonicity Hypertonicity Active movement Prime movement Prime combination Active movement Control and timing of muscles during movement Passive movement Starting position Palpation Passive movement Starting position Palpation Local stretch Effect on functional 0% PPIVMS Effect on functional 10% PAIVMS Effect on functional 40% Muscle contraction Effect on functional 10% The technique that alters movement and muscle tone most with mini-treatment is the initial treatment choice 64

15 The principles of combined movement assessment CHAPTER 4 s0200 p0600 s0205 p0610 Passive physiological intervertebral movement (PPIVMS) Due to the severity, the examination was undertaken in right lateral flexion and extension (posterior structures off stretch) to establish the movement that most reduced pain and dysfunction. Right lateral flexion induced the greatest increase in movement and reduction in muscle tone. A short passive treatment, using this right lateral flexion of C5 on C6 reduced the pain produced by the functional by 10%. Passive accessory intervertebral movement (PAIVMS) Due to the severity, examination was undertaken in right lateral flexion and extension (posterior structures off stretch) to establish the movement that most reduced pain and dysfunction. Anterior pressure (AP) on C5 induced the greatest increase in movement and reduction in muscle tone (greater than induced by AP movement of C4 or C6). A short passive treatment, using this accessory movement reduced the pain produced by the functional by 40%. Muscular assessment In right lateral flexion and extension due to severity of pain, palpation of musculature revealed hypertonicity of deep paraspinals (C4 to C6) and hypertonicity of the region s phasic muscles. No trigger points were detected. Palpation and length assessment of the levator scapulae, scalenes, upper fibres of trapezius and sternocleidomastoid did not alter the functional. See Figure s0210 p0620 p0630 b0035 LUMBAR SPINE CASE STUDY s0215 s0220 p0635 INITIAL INTERVIEW Symptomology A 45-year-old male sought treatment for pain in the right back and buttock (Fig. 4.21). The pain was not radicular in quality and not severe (4/10). There was no suggestion of an upper motor neuron lesion and no indication of other red flags. There were no features suggestive of segmental lumbar instability or disc derangement. There was no history of lumbar locking, catching or weakness and there was no cauda equina syndrome. Relevant history Symptoms developed over a 6-month-period with no history of trauma. Behaviour of symptoms Pain was reproduced with low lumbar extension and right lateral flexion (whilst arching his back to put on his coat). Standing reproduced symptoms within 20 minutes. Walking reproduced symptoms in 30 minutes. The symptoms were eased, immediately, by positioning the back in flexion, either by sitting or leaning over in standing. Pain was also eased by crossing the right leg over the left, in sitting. No latent pain was exhibited. Pain was also experienced whilst turning over in bed. s0225 p0640 s0230 p0645 Diurnal pattern There was less than 30 minutes of stiffness in the back in the morning. Buttock pain developed in the evening. Sleep was not disturbed. s0235 p0650 Special questions His general health was good. There was no weight loss, no night sweats or fever, no constant night pain (worse than during the day), no raised blood pressure, no symptoms of vascular stenosis or peripheral vascular disease. No history of cancer. The patient was not currently taking any anticoagulant or steroid therapy and had received no benefit from anti-inflammatory medication. s0240 p0655 f0110 Figure 4.21 Lumbar spine case study pain chart. See the completed planning sheet in Figure p

16 SECTION ONE Combined Movement Theory OBJECTIVE EXAMINATION PLAN List your hypotheses for the nature of the condition Superior facet capsule source Sacro-iliac joint source Anterior paraspinal muscle source... Which two hypotheses will you test against each other in the initial physical examination? Primary... Lumbar articular drive (75%)... Secondary... Sacro-iliac articular drive (25%)... Is the nature of the condition severe? Yes No Is the nature of the condition irritable? Yes No To what point are you allowing movement to occur? Before pain To pain To limit What is the functional /primary re-test marker?... Extension, ipsilateral lateral flexion quadrant... What is the primary pain mechanism of this patient s condition? Nociceptive Peripheral neurogenic Central Autonomic Affective To what extent will you perform a neurological exam? None required Local peripheral Lower motor neuron, upper motor neuron, limbs Lower motor neuron, upper motor neuron, limbs and cranial What is the weighting of the following components of the problem? % Radar plot Arthrogenic 70 Arthrogenic Myogenic Neurogenic 1 Osteogenic Myogenic Inflammagenic 4 50 Psychogenic 1 Viscerogenic Neurogenic 0 Sociogenic 1 Pathogenic 1 Pathogenic Inflammagenic Viscerogenic 1 Osteogenic 1 Sociogenic Psychogenic Likely first treatment: In: Extension, right lateral flexion quadrant... Will: Superior capsular stretch, large amplitude movement, in resistance (Grade III)... Comments/cautions: Pain relieving mobilization, combined with a stretch of the tissues driving the nociceptive pattern of presentation... f0115 Figure 4.22 Objective examination plan for the lumbar spine. 66

17 The principles of combined movement assessment CHAPTER 4 s0245 s0250 p0665 PHYSICAL EXAMINATION Observation There was no atrophy of the lumbar musculature. There was an increase in muscle tone of the right erectore spinae, quadratus lumborum and piriformis. s0255 Active movement p0670 Pain was reproduced earliest in range with right lateral flexion. Restriction to extension was apparent at the L4/L5 level. Pain was reproduced further into range with extension than with right lateral flexion. See Figure s0260 p0675 s0265 p0685 Passive physiological intervertebral movement (PPIVMS) Right lateral flexion, in extension of L4 on L5, induced the greatest increase in movement and reduction in muscle tone, when compared with movement at L3/L4 and L5/S1. A short passive treatment, using this right lateral flexion of L4 on L5 reduced the pain produced by the functional by 50%. Passive accessory intervertebral movement (PAIVMS) In right lateral flexion and extension, posterior pressure (unilateral posterior-anterior angled caudad) on L4 induced the greatest increase in movement and reduction in muscle tone, when compared to the same accessory movement appliedtol3orl5. Passive movement of the sacroiliac joint (SIJ) In right lateral flexion and extension PA pressure on the right apex of the sacrum (encouraging nutation) reproduced symptoms and was the most restricted sacral glide, when compared to the response of moving the other three corners of the sacrum. A short passive treatment, using this passive movement reduced the pain produced by the functional by 10%. See Figure First hypothesis Superior facet capsule sprain Observation Postural positioning malalignment Active movement Prime movement Prime combination Functional Extension, right lat flex Second hypothesis Restricted nutation of the right SIJ Observation Postural positioning malalignment Active movement Same Prime movement Prime combination s0270 p0695 p0705 A short passive treatment, using this accessory movement reduced the pain produced by the functional by 20%. Passive movement Starting position Palpation Passive movement Same Starting position Palpation SIJ passive movement Effect on functional 10% Right-sided lumbar and buttock pain Not severe PPIVMS Effect on functional 50% PAIVMS Effect on functional 20% Prime movement = right lateral flexion Prime combination = right lateral flexion followed by extension. 3 /4 full range The technique that most alters movement and pain response with mini-treatment is the initial treatment choice f0120 Figure 4.23 Box diagram showing the prime combination for the patient. Figure 4.24 Flow chart of differential examination for the lumbar spine. f

18 SECTION ONE Combined Movement Theory References Chaitow, L., Muscle energy techniques. Elsevier Health Sciences, Oxford. Gibbons, P., Tehan, P., 2001a. Patient positioning and spinal locking for lumbar spine rotation manipulation. Man. Ther. 6 (3), Gibbons, P., Tehan, P., 2001b. Spinal manipulation: indications, risks and benefits. Journal of Bodywork & Movement Therapies 5 (2), Grieve, G.P., Common vertebral joint problems. Churchill Livingstone, New York, pp Grieve, G.P., Mobilization of the spine. A Primary handbook of Clinical Method. Churchill Livingstone, Edinburgh. Kerry, R., Taylor, A.J., Mitchell, J., et al., 2008a. Manual therapy and cervical arterial dysfunction, directions for the future: a clinical perspective. The Journal of Manual & Manipulative Therapy 16 (1), Kerry, R., Taylor, A.J., Mitchell, J., et al., 2008b. Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice. Man. Ther. 13 (4), Maitland, G., Vertebral manipulation. Elsevier Health Sciences, Sydney. Travell, Simmons, Travell Simons myofascial pain and dysfunction: the trigger point manual, second ed. Lippincott Williams & Wilkins, San Francisco. 68